03 - 7.3 Schizophreniform Disorder

7.3 Schizophreniform Disorder

members to keep up with the changing nature and needs of these patients. Medication regimens can be complicated, with multiple medications from all classes of drugs. REFERENCES Bychkov ER, Ahmed MR, Gurevich VV, Benovi JL, Gurevich EV. Reduced expression of G protein-coupled receptor kinases in schizophrenia but not in schizoaffective disorder. Neurobiol Dis. 2011;44(2):248. Canuso CM, Lindenmayer JP, Kosik-Gonzalez C, Turkoz I, Carothers J, Bossie CA, Schooler NR. A randomized, doubleblind, placebo-controlled study of 2 dose ranges of paliperidone extended-release in the treatment of subjects with schizoaffective disorder. J Clin Psychiatry. 2010;71(5):587. Canuso CM, Schooler N, Carothers J, Turkoz I, Kosik-Gonzalez C, Bossie CA, Walling D, Lindenmayer JP. Paliperidone extended-release in schizoaffective disorder: A randomized, controlled study comparing a flexible dose with placebo in patients treated with and without antidepressants and/or mood stabilizers. J Clin Psychopharm. 2010;30(5):487. Cardno AG, Owen MJ. Genetic relationships between schizophrenia, bipolar disorder, and schizoaffective disorder. Schizophrenia Bulletin. 2014;40(3), 504–515. Fochtmann LJ, Mojtabai R, Bromet EJ: Other psychotic disorders. In: Sadock BJ, Sadock VA, Ruiz P, eds. Kaplan & Sadock’s Comprehensive Textbook of Psychiatry. 9th edition. Philadelphia: Lippincott Williams & Wilkins; 2009:1605. Glick ID, Mankoski R, Eudicone JM, Marcus RN, Tran QV, Assunção-Talbott S. The efficacy, safety, and tolerability of aripiprazole for the treatment of schizoaffective disorder: Results from a pooled analysis of a sub-population of subjects from two randomized, double-blind, placebo-controlled, pivotal trials. J Affect Disord. 2009;115(1–2):18. Hooper SR, Giuliano AJ, Youngstrom EA, Breiger D, Sikich L, Frazier JA, Findling RL, McClellan J, Hamer RM, Vitiello B, Lieberman JA. Neurocognition in early-onset schizophrenia and schizoaffective disorders. J Am Acad Child Adolescent Psychiatry. 2010;49:52. Kane JM. Performance improvement CME: Schizoaffective disorder. J Clin Psychiatry. 2011;72(7):e23. Kane JM. Strategies for making an accurate differential diagnosis of schizoaffective disorder. J Clin Psychiatry. 2010;71:4. Kane JM. The differential diagnosis of schizoaffective disorder. J Clin Psychiatry. 2010;71(12):e33. Kinnan S, Petty F, Wilson DR. Zolpidem-induced mania in a patient with schizoaffective disorder. Psychosomatics. 2011;52(5):493. Pandina G, Bilder R, Turkoz I, Alphs L. Identification of clinically meaningful relationships among cognition, functionality, and symptoms in subjects with schizophrenia or schizoaffective disorder. Schizophrenia research. 2013;143(2–3):312– 318. Salzer MS, Baron RC, Brusilovskiy E, Lawer LJ, Mandell DS: Access and outcomes for persons with psychotic and affective disorders receiving vocational rehabilitation services. Psychiatr Serv. 2011;62(7):796. 7.3 Schizophreniform Disorder The concept of schizophreniform disorder was introduced in 1939 by Gabriel Langfeldt (1895–1983) to describe a condition with a sudden onset and benign course associated with mood symptoms and clouding of consciousness. The symptoms of schizophreniform are similar to those of schizophrenia; however, with schizophreniform disorder, the symptoms last for at least 1 month but less than 6 months. In contrast, for a patient to meet the diagnostic criteria for schizophrenia, the symptoms must have been present for at least 6 months. Patients with schizophreniform disorder return to their baseline level

of functioning after the disorder has resolved. EPIDEMIOLOGY Little is known about the incidence, prevalence, and sex ratio of schizophreniform disorder. The disorder is most common in adolescents and young adults and is less than half as common as schizophrenia. A fivefold greater rate of schizophreniform disorder has been found in men than in women. A 1-year prevalence rate of 0.09 percent and a lifetime prevalence rate of 0.11 percent have been reported. Several studies have shown that the relatives of patients with schizophreniform disorder are at high risk of having other psychiatric disorders, but the distribution of the disorders differs from the distribution seen in the relatives of patients with schizophrenia and bipolar disorders. Specifically, the relatives of patients with schizophreniform disorders are more likely to have mood disorders than are the relatives of patients with schizophrenia. In addition, the relatives of patients with schizophreniform disorder are more likely to have a diagnosis of a psychotic mood disorder than are the relatives of patients with bipolar disorders. ETIOLOGY The cause of schizophreniform disorder is not known. As Langfeldt noted in 1939, patients with this diagnostic label are likely to be heterogeneous. In general, whereas some patients have a disorder similar to schizophrenia, others have a disorder similar to a mood disorder. Because of the generally good outcome, the disorder probably has similarities to the episodic nature of mood disorders. Some data, however, indicate a close relation to schizophrenia. In support of the relation to mood disorders, several studies have shown that patients with schizophreniform disorder, as a group, have more affective symptoms (especially mania) and a better outcome than patients with schizophrenia. Also, the increased occurrence of mood disorders in the relatives of patients with schizophreniform disorder indicates a relation to mood disorders. Thus, the biological and epidemiological data are most consistent with the hypothesis that the current diagnostic category defines a group of patients, some of whom have a disorder similar to schizophrenia; others have a disorder resembling a mood disorder. Brain Imaging A relative activation deficit in the inferior prefrontal region of the brain while the patient is performing a region-specific psychological task (the Wisconsin Card Sorting Test), as reported for patients with schizophrenia, has been reported in patients with schizophreniform disorder. One study showed the deficit to be limited to the left hemisphere and found impaired striatal activity suppression limited to the left hemisphere during the activation procedure. The data can be interpreted to indicate a physiological similarity between the psychosis of schizophrenia and the psychosis of

schizophreniform disorder. Additional central nervous system factors, as yet unidentified, may lead to either the long-term course of schizophrenia or the foreshortened course of schizophreniform disorder. Although some data indicate that patients with schizophreniform disorder may have enlarged cerebral ventricles, as determined by computed tomography and magnetic resonance imaging, other data indicate that, unlike the enlargement seen in schizophrenia, the ventricular enlargement in schizophreniform disorder is not correlated with either outcome or other biological measures. Other Biological Measures Although brain imaging studies point to a similarity between schizophreniform disorder and schizophrenia, at least one study of electrodermal activity indicated a difference. Patients with schizophrenia who were born during the winter and spring months (a period of high risk for the birth of these patients) had hyporesponsive skin conductances, but this association was absent in patients with schizophreniform disorder. The significance and the meaning of this single study are difficult to interpret, but the results do suggest caution in assuming similarity between patients with schizophrenia and those with schizophreniform disorder. Data from at least one study of eye tracking in the two groups also indicate that they may differ in some biological measures. DIAGNOSTIC AND CLINICAL FEATURES The DSM-5 criteria for schizophreniform disorder are listed in Table 7.3-1. Schizophreniform disorder is an acute psychotic disorder that has a rapid onset and lacks a long prodromal phase. Although many patients with schizophreniform disorder may experience functional impairment at the time of an episode, they are unlikely to report a progressive decline in social and occupational functioning. The initial symptom profile is the same as that of schizophrenia in that two or more psychotic symptoms (hallucinations, delusions, disorganized speech and behavior, or negative symptoms) must be present. Schneiderian first-rank symptoms are frequently observed. Also an increased likelihood is found of emotional turmoil and confusion, the presence of which may indicate a good prognosis. Although negative symptoms may be present, they are relatively uncommon in schizophreniform disorder and are considered poor prognostic features. In a small series of first-admission patients with schizophreniform, one-fourth had moderate to severe negative symptoms. Almost all were initially categorized as having “schizophreniform disorder without good prognostic features,” and 2 years later, 73 percent were rediagnosed with schizophrenia compared with 38 percent of those with “good prognostic features.” Table 7.3-1 DSM-5 Diagnostic Criteria for Schizophreniform Disorder

By definition, patients with schizophreniform disorder return to their baseline state within 6 months. In some instances, the illness is episodic, with more than one episode occurring after long periods of full remission. If the combined duration of symptomatology exceeds 6 months, however, then schizophrenia should be considered. Mr. C, a 28-year-old accountant, was brought to the emergency department by the police in handcuffs. He was disheveled, and shouted and struggled with the police officers. It was apparent that he was hearing voices because he would respond to them with shouts such as, “Shut up! I told you I won’t do it!” However, when confronted about the voices, he denied hearing anything. Mr. C had a hypervigilant stare and jumped at the slightest noise. He stated that he must run away quickly because he knew he would be killed shortly otherwise. Mr. C was functioning well until 2 months before hospitalization. He was an accountant at a prestigious company and had close friends and a live-in girlfriend. Most people who knew him would describe him as friendly, but he was occasionally quarrelsome. When his girlfriend suddenly broke off the relationship and moved out of their apartment, Mr. C was distressed. However, he was convinced that he could win her back, so he began to “accidentally” run into her at her job or her new apartment with flowers and various gifts. When she strongly told him that she wanted nothing more

to do with him and requested that he leave her alone, Mr. C was convinced that she wanted him dead. He became so preoccupied with this notion that his work began to suffer. Out of fear for his life, Mr. C took off from work frequently, and when he did report to work, he was often tardy and did subpar work, making many errors. His supervisor confronted Mr. C about his behavior, threatening termination if it continued. Mr. C was embarrassed and resented his supervisor for the confrontation. He believed that his ex-girlfriend had hired the supervisor to kill him. His beliefs were confirmed by a voice that would mock him. The voice told him time and again that he should quit his job, relocate to another city, and forget about his exgirlfriend, but Mr. C refused, believing it would give them “more satisfaction than they deserved.” He continued working, albeit cautiously, all the while fearing for his life. Through it all, Mr. C believed himself to be the lone victim. He would awake abruptly at night from nightmares but would be able to fall right back to sleep. He had not lost any weight and had no other vegetative symptoms. His affect alternated between rage and terror. His mind was unusually alert and active, but he was not otherwise hyperactive, excessively energetic, or expansive. He did not display any formal thought disorder. Mr. C was hospitalized and treated with antipsychotic medication. His symptoms remitted after several weeks of treatment, and he was well and able to return to work shortly after discharge. DIFFERENTIAL DIAGNOSIS It is important to first differentiate schizophreniform disorder from psychoses that can arise from medical conditions. This is accomplished by taking a detailed history and physical examination and, when indicated, performing laboratory tests or imaging studies. A detailed history of medication use, including over-the-counter medications and herbal products, is essential because many therapeutic agents can also produce an acute psychosis. Although it is not always possible to distinguish substance-induced psychosis from other psychotic disorders cross-sectionally, a rapid onset of psychotic symptoms in a patient with a significant substance history should raise the suspicion of a substanceinduced psychosis. A detailed substance use history and toxicological screen are also important for treatment planning in an individual with a new onset of psychosis. The duration of psychotic symptoms is one factor that distinguishes schizophreniform disorder from other syndromes. Schizophrenia is diagnosed if the duration of the prodromal, active, and residual phases lasts for more than 6 months; symptoms that occur for less than 1 month indicate a brief psychotic disorder. In general, a diagnosis of brief psychotic disorder does not require that a major stressor be present. Distinguishing mood disorders with psychotic features from schizophreniform disorder is sometimes difficult. Furthermore, schizophreniform disorder and schizophrenia can be highly comorbid with mood and anxiety disorders. Additional confounds are that mood

symptoms, such as loss of interest and pleasure, may be difficult to distinguish from negative symptoms, avolition, and anhedonia. Some mood symptoms may also be present during the early course of schizophrenia. A thorough longitudinal history is important in elucidating the diagnosis because the presence of psychotic symptoms exclusively during periods of mood disturbance is an indication of a primary mood disorder. COURSE AND PROGNOSIS The course of schizophreniform disorder, for the most part, is defined in the criteria. It is a psychotic illness lasting more than 1 month and less than 6 months. The real issue is what happens to persons with this illness over time. Most estimates of progression to schizophrenia range between 60 and 80 percent. What happens to the other 20 to 40 percent is currently not known. Some will have a second or third episode during which they will deteriorate into a more chronic condition of schizophrenia. A few, however, may have only this single episode and then continue on with their lives, which is clearly the outcome desired by all clinicians and family members, although it is probably a rare occurrence and should not be held out as likely. TREATMENT Hospitalization, which is often necessary in treating patients with schizophreniform disorder, allows effective assessment, treatment, and supervision of a patient’s behavior. The psychotic symptoms can usually be treated by a 3- to 6-month course of antipsychotic drugs (e.g., risperidone). Several studies have shown that patients with schizophreniform disorder respond to antipsychotic treatment much more rapidly than patients with schizophrenia. In one study, about 75 percent of patients with schizophreniform disorder and only 20 percent of the patients with schizophrenia responded to antipsychotic medications within 8 days. A trial of lithium (Eskalith), carbamazepine (Tegretol), or valproate (Depakene) may be warranted for treatment and prophylaxis if a patient has a recurrent episode. Psychotherapy is usually necessary to help patients integrate the psychotic experience into their understanding of their own minds and lives. ECT may be indicated for some patients, especially those with marked catatonic or depressed features. Finally, most patients with schizophreniform disorder progress to full-blown schizophrenia despite treatment. In those cases, a course of management consistent with a chronic illness must be formulated. REFERENCES Bobes J, Arango C, Garcia-Garcia M. Rejas J. Prevalence of negative symptoms in outpatients with schizophrenia spectrum disorders treated with antipsychotics in routine clinical practice: findings from the CLAMORS study. J Clin Psychiatry. 2010;71(3):280. Boonstra G, van Haren NEM, Schnack HG, Cahn W, Burger H, Boersma M, de Kroon B, Grobbee DE, Hulshoff P, Hilleke E, Khan RS. Brain volume changes after withdrawal of atypical antipsychotics in patients with first-episode